State fines Downey nursing home over diabetic patient's death in 2010

DOWNEY - The state fined a local skilled nursing and rehabilitation center $80,000 for "inadequate care" leading to a patient's death in 2010, public health officials said Tuesday.

The California Department of Public Health fined the Downey Rehabilitation Care Center at 13007 Paramount Blvd. after investigating a complaint concerning a woman who went into a diabetic coma and died.

Public health investigators concluded the woman went into the diabetic coma and died after the facility failed to check her blood sugar levels - even though the facility knew she had a history of diabetes, said Dr. Ron Chapman, state public health officer and director of the California Department of Public Health.

The Downey Rehabilitation Care Center also received an "AA" citation, the most severe penalty a facility can receive under state law. A second "AA" citation over the next two years could result in the the facility losing its license.

The Downey facility filed an appeal two days after the fine was issued on Jan. 24. This is its first fine by the state, Department of Public Health spokesman Ralph Montano said.

The woman who died was not named by the state due to federal privacy laws.

She was admitted four times to the center in 2009, according to the state report. Each time, a physician ordered blood sugar monitoring and insulin dosages.

The patient was readmitted to the facility in 2010 with a recurrent urinary tract infection, nausea, vomiting and dehydration. But the admitting documents didn't include medications for diabetes or orders to monitor blood glucose levels.

After 29 days without blood glucose monitoring, her breathing was shallow, and nurses could not obtain vital signs. The nursing home called 911 and paramedics transported her to a local hospital, according to the report.

Nursing home staff told investigators they didn't check the patient's blood sugar levels because they didn't have a doctor's order. The patient's blood sugar was checked the day she was transferred to a hospital "because it was an emergency," according to the report.

Doctors at the hospital said the woman, who was on a breathing tube, was "deeply comatose clinically consistent with brain death." Family members removed her breathing tube, and she was pronounced dead.

The cause of death was listed as septic shock, urosepsis, diabetic ketoacidosis and diabetes mellitus type II, according to the report.

In response to the report, the facility was required to file a plan of correction with state, Montano said.

Officials at the facility said they would review all records of patients with diabetes. For those patients who didn't have blood glucose monitoring, their physicians would be notified and requested to monitor the blood glucose levels.

Patients who are admitted with diabetes would have their records reviewed by a physician, who would determine their blood glucose monitoring and medication needs, according to the report.